f 0554 - in.gov

(X1) PROVIDER/SUPPLIER/CLIA

DEPARTMENT OF HEALTH AND HUMAN SERVICES

CENTERS FOR MEDICARE & MEDICAID SERVICES

11/14/2019PRINTED:

FORM APPROVED

OMB NO. 0938-039

STATEMENT OF DEFICIENCIES

AND PLAN OF CORRECTION IDENTIFICATION NUMBER

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NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP COD

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SUMMARY STATEMENT OF DEFICIENCIE

(EACH DEFICIENCY MUST BE PRECEDED BY FULL

REGULATORY OR LSC IDENTIFYING INFORMATION

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IDPROVIDER'S PLAN OF CORRECTION

(EACH CORRECTIVE ACTION SHOULD BE

DEFICIENCY)

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DATECROSS-REFERENCED TO THE APPROPRIATE

NOBLESVILLE, IN 46060

155779 10/15/2019

PRAIRIE LAKES HEALTH CAMPUS

9730 PRAIRIE LAKES BLVD EAST

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This visit was for a Recertification and State

Licensure Survey. This visit included a State

Residential Licensure Survey.

Survey dates: October 7, 8, 9, 10, 11, and 15, 2019

Facility number: 012305

Provider number: 155779

AIM number: 200987990

Census Bed Type:

SNF/NF:27

SNF: 16

Total: 43

Census Payor Type:

Medicare: 16

Medicaid: 24

Other: 3

Total: 43

These deficiencies reflect State Findings cited in

accordance with 410 IAC 16.2-3.1.

Quality reveiw completed on October 21, 2019.

F 0000 Preparation or execution of

this plan of correction does not

constitute admission or

agreement of provider of the

truth of the facts alleged or

conclusions set forth on the

Statement of Deficiencies. The

Plan of Correction is prepared

and executed solely because it

is required by the position of

Federal and State Law. The

Plan of Correction is submitted

in order to respond to the

allegation of noncompliance

cited during a Recertification

and State Licensure Survey

that was conducted on,

October 15, 2019. Please

accept this plan of correction

as the provider's credible

allegation of compliance as of,

November 12, 2019. The

provider respectfully requests a

desk review with paper

compliance to be considered in

establishing that the provider is

in substantial compliance.

483.10(c)(7)

Resident Self-Admin Meds-Clinically Approp

§483.10(c)(7) The right to self-administer

medications if the interdisciplinary team, as

defined by §483.21(b)(2)(ii), has determined

that this practice is clinically appropriate.

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Based on observation, record review and

interview, the facility failed to evaluate residents

F 0554 F-554: Facility failed to evaluate

residents for self-administration of

medications for 2 of 2 residents

11/12/2019 12:00:00AM

FORM CMS-2567(02-99) Previous Versions Obsolete

Any defiencystatement ending with an asterisk (*) denotes a deficency which the institution may be excused from correcting providing it is determin

other safegaurds provide sufficient protection to the patients. (see instructions.) Except for nursing homes, the findings stated above are disclosable

following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclo

days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to

continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

_____________________________________________________________________________________________________Event ID: 3T9X11 Facility ID: 012305

TITLE

If continuation sheet of 24

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for self-administration of medications for 2 or 2

residents observed to have medications at

bedside. (Residents 14 and 203)

1. During an interview with Resident 14 on 10/8/19

at 9:17 a.m., a bottle of fluticasone nasal spray was

observed on the resident's bedside table. The

resident indicated she administered it herself.

The resident's clinical record was reviewed on

10/09/19 at 10:24 a.m. Diagnoses included, but

were not limited to, acute cystitis without

hematuria, muscle weakness, allergic rhinitis, and

encephalopathy.

The clinical record lacked an evaluation for the

resident to self administer the medication.

A current physician's order, dated 1/8/18,

indicated fluticasone spary 50mcg/actuation, 2

sprays in each nostril one time a day between 6:00

a.m. and 10:00 a.m.

During an interview on 10/10/19 at 1:43 p.m., the

Nurse Consultant indicated the fluticasone nasal

spray should not have been left in the resident's

room. 2. A random observation on 10/09/19 9:38

a.m., Resident 203 was walking toward her room.

She indicated she had to come back and take her

pills, she left them in her room and went to eat

because she wanted something on her stomach.

The resident walked into her room, a cup of three

pills was sitting on her over the bed table, and the

resident took the medication without a nurse

present.

The clinical record for Resident 203 was reviewed

on 10/09/19 at 08:29 a.m., Diagnoses for the

resident included but were not limited to,

hypertension, head injury, localized edema.

observed to have medication at

bedside.

Corrective actions

accomplished for those

residents found to be affected

by the alleged deficient

practice: No ill effects were

noted for 2 of the 2 residents

observed, nasal spray was

removed from resident 14 bedside,

resident 203 consumed all

morning scheduled medications

without incident. RN #4, was

immediately educated on the,

“Guidelines for Self Administration”

and medication administration

guidelines. At time of notification,

all other resident rooms were

observed to ensure no other

medications were left at resident

bedside, no other concerns

identified at that time.

Identification of other residents

having the potential to be

affected by the same alleged

deficient practice and

corrective actions taken: All

residents have the potential to be

affected by the alleged deficient

practice. DHS began immediate

education on the “Guidelines for

Self-Administration” for nursing

staff, education is on-going.

Measures put in place and

systemic changes made to

ensure the alleged deficient

practice does not recur: DHS or

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3T9X11 Facility ID: 012305 If continuation sheet of 24




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Current signed physician's orders for the resident

included, but were not limited to, the following

orders:

a. Senna with Docusate sodium (stool softener

medication) give 17.2-100 milligrams by mouth

twice a day; 6:00 a.m. - 10:00 a.m., and 7:00 p.m. -

10:00 p.m. The order originated on 9/28/19.

b. Cholecalciferol (Vitamin D3) give 1,000 units by

mouth once a day; 6:00 a.m. - 10:00 a.m. The order

originated on 9/29/19.

c. Folic acid (supplement) give one tablet by

mouth once a day; 6:00 a.m. - 10:00 a.m. The order


The resident had a 8/12/19, quarterly Minimum

Data Set (MDS) assessment, which indicated the

resident had moderate cognitive impairment, poor

decision making.

The resident's clinical record lacked an order for

self administration of medication, or an

assessment to self administrate medication.

During an interview on 10/9/19 at 9:43 a.m., RN 4

indicated she took the residents medication into

her room, sat them down on the table. She came

out of the resident's room due to the resident was

in the bathroom. The nurse indicated she did not

see the resident take her medication. RN 4

indicated she should had remained in the room

until the residents had taken her medication.


DON indicated no residents in the health center

self administrates medications.

designee will educate all nursing

staff on “Guidelines of

Self-Administration” and

“Medication Administration”.

How the corrective measures

will be monitored to ensure the

alleged deficient practice does

not recur: DHS or designee will

observe 5 resident rooms during

general medication pass times to

ensure no medications are left at

bedside without proper evaluation

and orders in place, 2 times per

week X8 weeks, weekly X4 weeks,

bi-weekly X4 weeks, then monthly

ongoing.

For quality assurance, the ED or

designee will review audit results

and subsequent corrective action

at least quarterly in the campus

Quality Assurance Committee

meeting. The plan will be revised

as warranted. If increased

problems noted, audit frequency

may increase. If no problems

noted after six months, the

frequency of audits may decrease.





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Review of the current facility policy, revised

5/22/2018, titled "Guidelines for Self

Administration of Medication" provided by the

Corporate Nurse on 10/9/19 at 10:17 a.m.,

included, but was not limited to,

"Policy: To ensure the safe administration of

medication for residents who request to self -

medicate or when self -medication is a part of their

pan of care.

Procedure:

1. Residents shall be assessed using the

observation Trilogy-Self Administration of

Medication... results of the assessment will be

presented to the physician for evaluation and an

order for self - medication..."

3.1-11(a)

483.25(g)(1)-(3)

Nutrition/Hydration Status Maintenance

§483.25(g) Assisted nutrition and hydration.

(Includes naso-gastric and gastrostomy

tubes, both percutaneous endoscopic

gastrostomy and percutaneous endoscopic

jejunostomy, and enteral fluids). Based on a

resident's comprehensive assessment, the

facility must ensure that a resident-

§483.25(g)(1) Maintains acceptable

parameters of nutritional status, such as

usual body weight or desirable body weight

range and electrolyte balance, unless the

resident's clinical condition demonstrates

that this is not possible or resident

preferences indicate otherwise;

§483.25(g)(2) Is offered sufficient fluid intake

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to maintain proper hydration and health;

§483.25(g)(3) Is offered a therapeutic diet

when there is a nutritional problem and the

health care provider orders a therapeutic diet.

Based on record review and interview, the facility

failed to ensure a fluid restriction was followed per

physician's order for 1 of 1 resident's reviewed for

hydration. (Resident 33)

Findings include:

A review of Resident 33's clinical record was

completed on 10/11/19 at 12:53 p.m. Diagnoses

included, but were not limited to, dementia

without behaviors, heart failure, and

hyponatremia.

He had current physician order, dated 8/9/19, for a

fluid restriction of 1200 ml (milliliter) per day. The

order included the following:

a. 240 ml per meal from dining services.

b. 240 ml per day shift from nursing.

c. 120 ml per evening shift from nursing.

d. 120 ml per night shift from nursing.

A significant change Minimum Data Set (MDS)

assessment, dated 8/30/19, indicated he had

severe cognitive impairment and required

extensive assistance to eat and drink.

Review of the resident's care plan lacked any

information for a diagnosis of hyponatremia or

indication of a fluid restriction.

A review of a progress note, dated 8/22/19, the

nurse practitioner indicated the following:

"Plan:

1. Hyponatrimia...not improving. Off diuretic, on

F 0692 F-692: Facility failed to ensure a

fluid restriction was followed per

physician’s order for 1 of 1

resident’s reviewed for hydration

Corrective actions




practice: No ill effects noted for

resident 33, fluid restriction has

been discontinued.






resident’s with fluid restriction

orders have the potential to be


practice. Orders and fluid

consumption for the last 30 days

were reviewed for all residents with

fluid restrictions at time of

identification, findings reviewed

with provider. New process in

place for documentation of fluid

consumption.


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fluid restriction 1200 cc..."

Review of the nursing fluid intake documentation

from the eMAR (electronic medication

administration record), indicated the following:

a. For September 2019, documentation was

present for greater than 240 ml's as provided on 8

of 30 day shifts; greater than 120 ml's provided on

16 of 30 evening shifts; and greater than 120 ml's

provided on 1 of 30 night shifts.

b. For October 2019, documentation was present

for greater than 240 ml's as provided on 2 of 11

day shifts and greater than 120 ml's provided on 4

of 10 evening shifts.

Review of the CNA's fluid intake documentation

from the electronic health record (EHR) indicated

the following:

a. For September 2019, documentation was

present for greater than 720 ml's per day, or 240

ml's per meal, for 30 of 30 days reviewed, with an

average overage of fluids documented at 1605 ml's

per day.

b. For October 2019, documentation was present

for greater than 720 ml's per day, or 240 ml's per

meal, for 10 of 10 days reviewed, with an average

overage of fluids documented at 1206 ml's per day.

During an interview on 10/15/19 at 9:55 a.m., the

Nurse consultant indicated the resident's fluid

restriction documentation had been reviewed and

had not been followed.

Review of a current facility policy, titled

"Guidelines for Fluid Restriction," dated 5/11/16

and provided by the Nurse Consultant on




designee will re-educate all

nursing staff on “Guidelines for

Fluid Restriction” and the current

process for documentation of fluid

consumption.





review fluid consumption records

for up to 5 residents with fluid

restrictions in place, 2 times per



on-going.
















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10/15/19 at 9:56 a.m., indicated the following:

"PURPOSE: To ensure fluids are provided within

the physician order guidelines.

PROCEDURES...

5. The Nursing Department shall record

established breakdown by shift and document in

the EHR.

6. Fluid consumption shall be reviewed by shift to

determine adjustments necessary in the fluid

intake of the resident on the restriction in order to

meet their established fluid needs."

3.1-46(a)(1)

483.45(a)(b)(1)-(3)

Pharmacy

Srvcs/Procedures/Pharmacist/Records

§483.45 Pharmacy Services

The facility must provide routine and

emergency drugs and biologicals to its

residents, or obtain them under an agreement

described in §483.70(g). The facility may

permit unlicensed personnel to administer

drugs if State law permits, but only under the

general supervision of a licensed nurse.

§483.45(a) Procedures. A facility must

provide pharmaceutical services (including

procedures that assure the accurate

acquiring, receiving, dispensing, and

administering of all drugs and biologicals) to

meet the needs of each resident.

§483.45(b) Service Consultation. The facility

must employ or obtain the services of a

licensed pharmacist who-

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§483.45(b)(1) Provides consultation on all

aspects of the provision of pharmacy services

in the facility.

§483.45(b)(2) Establishes a system of

records of receipt and disposition of all

controlled drugs in sufficient detail to enable

an accurate reconciliation; and

§483.45(b)(3) Determines that drug records

are in order and that an account of all

controlled drugs is maintained and

periodically reconciled.

Based on record review, and interview, the facility

failed to ensure physician orders were followed

related to dementia care for 1 of 3 residents

reviewed for dementia care. (Resident 3)

Findings include:

The clinical record for Resident 3 was reviewed on

10/10/19 at 9:09 a.m., Diagnoses for the resident

included but were not limited to, dementia with

behavioral disturbance, psychotic disorder with

hallucinations, Alzheimer's disease, and anxiety

disorder.



orders:

a. Olanzapine (psychotic medication) give 2.5

milligram by mouth once a day at 9:00 a.m. for

psychotic disorder with hallucinations. The order




F 0755 F-755: Facility failed to ensure

physician orders were followed

related to dementia care for 1 of 3

residents reviewed for dementia

care.

Corrective actions




practice: Resident 3, medication

administration history for the last

30 days were reviewed, current

orders were compared to

medications available for

administration in the med cart to

ensure all medications were

available for administration, all

medications were available at time

of review, all findings were

reviewed with provider. Resident

remained at baseline with moods

and behaviors at that time.

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resident had severe cognitive impairment, with

hallucinations (perceptual experiences in the

absence of real external sensory stimuli) and

delusions (misconceptions or beliefs that are

firmly held, contrary to reality).

The resident had a current, start date 12/13/18,

health care plan with the problem of

"Psychotropic drug use. The resident is at risk for

adverse consequences related to receiving

antipsychotic medication for: psychotic disorder

with hallucinations . Approaches for this problem

included but were not limited to: administer

medication per physician order, and pharmacy

consultant review as needed.

A review of the residents medication

administration history indicated the following:

8/16/19 at 8:30 a.m., medication not administered

due to drug unavailable, comment: refilled

requested.

8/19/19 at 8:39 a.m., medication not administered

due to drug unavailable, comment: refilled

requested.

b. Olanzapine (psychotic medication) give 2.5

milligram by mouth once a day at 2:00 p.m. - 10:00

p.m. for psychotic disorder with hallucinations.

The order originated on 1/9/19.

A review of the residents medication

administration history indicated the following:

8/13/19 at 7:22 p.m., medication not administered

due to drug unavailable, the comment indicated

the medication was refilled on 7/26/19, but they

were unable to locate.






residents with dementia with an

order for an antipsychotic

medication, have the potential to

be affected by the alleged deficient

practice. All resident’s with

dementia who take an

antipsychotic medication, had

administration records reviewed for

the last 30 days. Medication

orders were compared to meds

available in the cart for

administration, all meds were

available to administer, all findings

reviewed with provider.






nursing staff on “Medication

Ordering and Receiving From

Pharmacy” and provider

notification. Nursing leadership

educated on the, “Administration

Compliance Report/review”.





review administration compliance

and observe medication carts to





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due to drug unavailable.











8/20/19 at 6:43 p.m. medication not administered

due to drug unavailable, comment: refilled to early.

The resident's clinicial record lacked notification

to the physician related to his missed medication.


Corporate Nurse indicated the Olanzapine

scheduled at 2:00 p.m. - 10:00 p.m., had been

transcribed as an additional order. She indicated

it should had been written for two times a day.

The facility did not have Olanzapine available for

emergencies or missed doses.

Review of the current facility policy, revised 1/17,

titled "MEDICATION ORDERING AND

RECEIVING FROM PHARMACY" provided by

the Corporate Nurse on 10/15/19 at 10:25 a.m.,


"Policy: Medication and related products are

received from the dispensing pharmacy. The

ensure meds are available as

ordered, for up to 5 residents with

a diagnosis of dementia with an

active order for an antipsychotic

medication; 2 times per week X8

weeks, weekly X8 weeks,


on-going.
















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facility maintains accurate records of medication

order and receipt.

Procedures:

...2. Reorder medication several days in advance

of need, as directed by the pharmacy order and

delivery schedule, to assure an adequate supply

is on hand...

3. "Stat" and emergency medications are ordered

as follows:

During regular pharmacy hours, the pharmacy is

notified of the emergency order; the order is then

phoned, sent electronically, or faxed to the

pharmacy. Such medications are delivered and

administered upon delivery..."

3.1-25(a)

483.45(d)(1)-(6)

Drug Regimen is Free from Unnecessary

Drugs

§483.45(d) Unnecessary Drugs-General.

Each resident's drug regimen must be free

from unnecessary drugs. An unnecessary

drug is any drug when used-

§483.45(d)(1) In excessive dose (including

duplicate drug therapy); or

§483.45(d)(2) For excessive duration; or

§483.45(d)(3) Without adequate monitoring;

or

§483.45(d)(4) Without adequate indications

for its use; or

§483.45(d)(5) In the presence of adverse

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consequences which indicate the dose

should be reduced or discontinued; or

§483.45(d)(6) Any combinations of the

reasons stated in paragraphs (d)(1) through

(5) of this section.

Based on record review, and interview the facility

failed to ensure all medication had an order prior

to administration for for 1 of 5 residents reviewed

for unnecessary medication. (Resident 47)

Findings include:

The clinical record for Resident 47 was reviewed

on 10/11/19 at 9:21 a.m., Diagnoses for the

resident included but were not limited to,

dementia, cerebrovascular disease, hypertension,

chronic atrial fibrillation, hemiplegia and

hemiparesis.

The resident had a 6/28/19,quarterly Minimum


resident had severe cognitive impairment.



orders:

a. check blood pressure every six (6) hours, if SBP

(systolic blood pressure) is greater than 180 give

as needed hydralazine (blood pressure

medication) per order. The order originated on

10/11/18.

The residents medication administration history

lacked an order for hydralazine.

The residents administration history indicated the

order for hydralazine 25 milligrams give one tablet

every six (6) hours as needed for SBP greater than

F 0757 F-757: Facility failed to ensure all

medications had an order prior to

administration for 1 of 5 residents

reviewed for unnecessary

medication.

Corrective actions




practice: Resident 47 without ill

effects noted, medication card

immediately removed from med

cart, blood pressure order clarified,

“prn hydralazine” discontinued.







affected by the same deficient

practice. All residents residing in

health center had their medication

orders compared to the

medications available in the

medication cart, all findings

reviewed with provider and

pharmacy, no medications remain

available for administration without

active physician orders in place.

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180 was discontinued on 4/29/19.

The medication administration history indicated

hydralizine was administered without an order on

the following dates and times:

a. On 7/28/19 at 12:00 a.m.

b. On 8/21/19 at 6:00 a.m.

c. On 9/21/19 at 6:00 p.m.

Review of the current facility policy, revised 1/17,

titled "MEDICATION ORDERING AND

RECEIVING FROM PHARMACY" provided by

the Corporate Nurse on 10/15/19 at 10:25 a.m.,


"Policy: Medication and related products are

received from the dispensing pharmacy. The

facility maintains accurate records of medication

order and receipt.

3.1-25(e)(3)






nursing staff on “Medication

Ordering and Receiving From

Pharmacy” and provider

notification.





observe 5 residents residing in

health center, comparing active

physician orders with medications

available in medication cart to

ensure there are no medications

available for administration without

provider orders in place, 2 times

per week X8 weeks, weekly X4

weeks, bi-weekly X4 weeks, then

monthly on-going.













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483.45(c)(3)(e)(1)-(5)

Free from Unnec Psychotropic Meds/PRN

Use

§483.45(e) Psychotropic Drugs.

§483.45(c)(3) A psychotropic drug is any

drug that affects brain activities associated

with mental processes and behavior. These

drugs include, but are not limited to, drugs in

the following categories:

(i) Anti-psychotic;

(ii) Anti-depressant;

(iii) Anti-anxiety; and

(iv) Hypnotic

Based on a comprehensive assessment of a

resident, the facility must ensure that---

§483.45(e)(1) Residents who have not used

psychotropic drugs are not given these drugs

unless the medication is necessary to treat a

specific condition as diagnosed and

documented in the clinical record;

§483.45(e)(2) Residents who use

psychotropic drugs receive gradual dose

reductions, and behavioral interventions,

unless clinically contraindicated, in an effort

to discontinue these drugs;

§483.45(e)(3) Residents do not receive

psychotropic drugs pursuant to a PRN order

F 0758

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unless that medication is necessary to treat

a diagnosed specific condition that is

documented in the clinical record; and

§483.45(e)(4) PRN orders for psychotropic

drugs are limited to 14 days. Except as

provided in §483.45(e)(5), if the attending

physician or prescribing practitioner believes

that it is appropriate for the PRN order to be

extended beyond 14 days, he or she should

document their rationale in the resident's

medical record and indicate the duration for

the PRN order.

§483.45(e)(5) PRN orders for anti-psychotic

drugs are limited to 14 days and cannot be

renewed unless the attending physician or

prescribing practitioner evaluates the resident

for the appropriateness of that medication.

Based on record review, and interview, the facility

failed to monitor for antipsychotic medication side

effects and behavior monitoring for 1 of 5

residents review for psychotropic medication.

(Resident 3)

Findings include:

The clinical record for Resident 3 was reviewed on

10/10/19 at 9:09 a.m., Diagnoses for the resident

included but were not limited to, dementia with

behavioral disturbance, psychotic disorder with

hallucinations, Alzheimer's disease, anxiety

disorder, and major depressive disorder.



resident had severe cognitive impairment, with

hallucinations (perceptual experiences in the

absence of real external sensory stimuli) and

delusions (misconceptions or beliefs that are

F 0758 F-758: Facility failed to monitor

for antipsychotic medication side

effects and behavior monitoring for

1 of 5 residents reviewed for

psychotropic medication.

Corrective actions




practice: Resident 3, side

effect and target behavior

monitoring was reinitiated for

resident psychotropic

medications. Resident has

shown improvement in moods

and behaviors since return to

facility with current regimen in

place, continues to be followed

by psych services, findings

reviewed with provider.

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firmly held, contrary to reality).



orders:

a. Olanzapine (antipsychotic medication) give 2.5

milligram by mouth twice a day at 8:00 a.m. and

5:00 p.m., for psychotic disorder with

hallucinations. The order originated on 9/13/19.

b. Depakote Sprinkles (mood stabilizer) give 250

milligrams twice a day at 6:00 a.m.-10:00 a.m., and

6:00 p.m.-10:00 p.m., for mood instability. The

order originated on 9/13/19.


health care plan with the problem of Psychotropic

drug use. The resident had a diagnosis of

psychotic disorder with hallucinations due to

known physiological condition he requires the

use of antipsychotic medication Zyprexa

(Olanzapine) as evident by agitation, accusatory

statements, restlessness, insomnia and repetitive

questions/statements. Approaches for this

problem included but were not limited to:

administer medication per physician order, and

monitor for changes in status and inform

physician /family.


health care plan with the problem of Psychotropic

drug use. The resident had a diagnoses of major

depression disorder he requires the use of

medications Depakote as evident by up/down

mood, statements of feeling down, lack of interest,

feeling tired, change in sleep, changes in appetite

and isolation in room. Approaches for this

problem included but were not limited to:

administer medication per physician order.






residents with an order for an

antipyschotic medication have the

potential to be affected by the

alleged deficient practice. All

residents with an active

antipsychotic medication order

had a chart review conducted to

ensure all side effect and target

behavior monitoring is in place.

Findings reviewed with provider.

All residents with antipsychotic

medication orders have side effect

and target behavior monitoring in

place.






nursing staff on “Psychotropic

Medication Usage”, side effect

monitoring, target behavior

tracking, and care tracker

documentation.





review up to 5 resident charts, for

residents with an active

antipsychotic order in place, to

ensure side effect and target





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A progress note, dated 9/9/19 at 3:20 p.m.,

indicated the resident was transported to a

psychiatric treatment facility for treatment.

A progress note, dated 9/13/19 at 8:07 p.m.,

indicated the resident returned to the facility.

A review of the resident medication administration

history for September 13, 2019 through October

10, indicated the targeted behavior monitoring

was discontinued on 9/9/19 and was not

reinitiated upon the resident's return to the

facility.

During an interview on 10/10/19 at 1:05 p.m., LPN

1 indicated behavior and medication monitoring

should be done on the medication administration

sheet or in the nurse notes.


Corporate Nurse indicated the antipsychotic

medication and targeted behavior monitoring

should have been reinitiated upon the residents

return to the facility

Review of the current facility policy, revised

10/9/17, titled "Psychotropic Medication Usage"

provided by the Corporate Consultant on

10/15/19 at 10:10 a.m., included, but was not

limited to,

"PURPOSE: To ensure every effort is made for

residents receiving psychoactive medications to

obtain the maximum benefit with minimal

unwanted side effects through appropriate use,

evaluation and monitoring by the interdisciplinary

team.

Procedures:

behavior monitoring orders are in

place, 2 times per week X8

weeks, weekly X8 weeks,


on-going.
















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...7. Review of medication use will be conducted

by the consultant pharmacist monthly and will

monitor psychotropic drug use in the campus

to ensure that medications are not used in

excessive doses or for excessive duration..."

3.1-48(a)(3)

483.45(g)(h)(1)(2)

Label/Store Drugs and Biologicals

§483.45(g) Labeling of Drugs and Biologicals

Drugs and biologicals used in the facility

must be labeled in accordance with currently

accepted professional principles, and include

the appropriate accessory and cautionary

instructions, and the expiration date when

applicable.

§483.45(h) Storage of Drugs and Biologicals

§483.45(h)(1) In accordance with State and

Federal laws, the facility must store all drugs

and biologicals in locked compartments

under proper temperature controls, and

permit only authorized personnel to have

access to the keys.

§483.45(h)(2) The facility must provide

separately locked, permanently affixed

compartments for storage of controlled drugs

listed in Schedule II of the Comprehensive

Drug Abuse Prevention and Control Act of

1976 and other drugs subject to abuse,

except when the facility uses single unit

package drug distribution systems in which

the quantity stored is minimal and a missing

dose can be readily detected.

F 0761

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Based on observation and interview, the facility

failed to appropriately label medications brought F 0761 F-761: Facility failed to

appropriately label medications 11/12/2019 12:00:00AM





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to the facility by the resident or resident

representative in 2 of 2 medication carts observed

for medication storage. (100 hall and 200 hall

medication carts)

Findings include:

1. During a medication storage observation of the

100 hall medication cart on 10/7/19 at 10:21 a.m.,

accompanied by LPN 1, the following was

observed:

a. An opened bottle of Dye-free Wal-Dry

(medication to treat allergies) 12.5mg (milligram),

lacked a resident name. LPN 1 indicated the

container had 15 of 20 doses remaining.

b. An opened bottle of Mucus Relief ER 600 mg,

lacked a resident name. LPN 1 indicated the

container had 11 of 20 doses remaining.

2. During a medication storage observation of the

200 hall medication cart on 10/7/19 at 10:41 a.m.,

accompanied by CRMA 3, the following was

observed:

a. An opened bottle of Acetaminophen PM

(medication to treat pain and promote sleep),

lacked a resident name. CRMA 3 indicated the

container was approximately 1/2 full.


Nurse Consultant indicated medications brought

to the facility by residents or resident families

should be labeled with the resident name.

Review of current facility policy provided by the

Nurse Consultant on 10/15/19 at 11:25 a.m., titled

"Medication Ordering and Receiving From

Pharmacy", indicated the following:

brought to the facility by the

resident or resident representative

in 2 of 2 medication carts

observed for medication storage.

Corrective actions




practice: All medication carts

were audited to ensure all

medications brought into the

facility and stored in the

medication carts were labeled

appropriately with the resident

name/room #, medication and

strength, directions, doctor,

and date received.






residents who provide medication

from an outside source have the

potential to be affected by the

alleged deficient practice. All

medication carts were audited to

ensure all medications brought

into the facility and stored in the

medication carts were labeled

appropriately with the resident

name/room #, medication and

strength, directions, doctor, and

date received.






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"MEDICATIONS BROUGHT TO THE FACILITY

BY A RESIDENT OR RESPONSIBLE PARTY...

A. Use of medications brought to the facility by a

resident or responsible party is allowed only when

the following conditions are met:...

3) The medication container is clearly labeled in

accordance with facility procedures for medication

labeling..."

3.1-25(j)





nursing staff on the pharmacy

policy for “Medications Brought to

the Facility by a Resident or

Responsible Party”, labeling of

these medications, and

“Medication Storage”.





audit all health center medication

carts, to ensure all medications

brought into the facility by the

resident or responsible party are

labeled appropriately, 2 times per



on-going.







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R 0000

Bldg. 00

This visit was for a State Residential Licensure

Survey.

Survey dates: October 7, 8, 9, 10, 11, and 15, 2019

Facility number: 012305

Residential Census:13

These State Residential Findings are cited in

accordance with 410 IAC 16.2-5.

Quality review completed on October 21, 2019.

R 0000 Preparation or execution of

this plan of correction does not

constitute admission or

agreement of provider of the

truth of the facts alleged or

conclusions set forth on the

Statement of Deficiencies. The

Plan of Correction is prepared

and executed solely because it

is required by the position of

Federal and State Law. The

Plan of Correction is submitted

in order to respond to the

allegation of noncompliance

cited during a Recertification

and State Licensure Survey

that was conducted on,

October 15, 2019. Please

accept this plan of correction

as the provider's credible

allegation of compliance as of,

November 12, 2019. The

provider respectfully requests a

desk review with paper

State Form Event ID: 3T9X11 Facility ID: 012305 If continuation sheet of 24




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compliance to be considered in

establishing that the provider is

in substantial compliance.

R 9999

Bldg. 00

Based on interview and record review, the facility

failed to ensure a staff member was CPR certified

for 3 of 21 shifts reviewed for the week of staffing

provided by the facility.

Findings include:

A review of the employee schedule on 10/15/19 at

11:43 a.m., lacked any staff members that were

CPR certified for three of 21 shifts, reviewed for

the week of 9/30/19 through 10/6/19.

During an interview, on 10/15/19 at 1:33 p.m., the

Corporate Consultant indicated they did not have

CPR coverage for the three shifts.

No further information received from facility.

R 9999 R-9999: Facility failed to ensure

that a CPR certified staff member

was present for 3 out of 21 shifts.

Corrective actions




practice: No incidents

requiring CPR occurred during

the 3 identified shifts of

non-coverage, HC staff was

available during these 3 shifts

for CPR coverage of the AL unit

had a situation arisen requiring

intervention.








practice. All residential nursing

staff employee records were

reviewed to determine CPR

certification status. DHS or


staff on R9999, ensuring a CPR

certified staff member is present at

all times in the residential setting;

all nursing employees working in

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the residential setting will renew or

obtain CPR certification.






staff on R9999, ensuring a CPR

certified staff member is present at

all times in the residential setting;

all nursing employees working in

the residential setting will renew or

obtain CPR certification.





audit the schedule to ensure a

nursing staff member with CPR

certification is scheduled on the

residential unit at all times, 3

times per week X8 weeks, 2 times

per week X4 weeks, weekly X4

weeks, then monthly ongoing.






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